The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
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Influence of Left Ventricular Diastolic Dysfunction on Ischemic Heart Disease in Patients with Chronic Kidney Disease

만성 실질환 환자에서 허혈성 심질환에 대한 좌심실 이완기능 장애의 영향

  • Choi, Bo-Kyung (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Lee, Kyung-Nam (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Hwang, In-Hye (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Kim, Il-Young (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Rhee, Ha-Rin (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Seoung, Eun-Young (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Song, Sang-Heon (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Lee, Dong-Won (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Lee, Soo-Bong (Department of Internal Medicine, Pusan National University School of Medicine) ;
  • Kwak, Ihm-Soo (Department of Internal Medicine, Pusan National University School of Medicine)
  • 최보경 (부산대학교 의학전문대학원 내과학교실) ;
  • 이경남 (부산대학교 의학전문대학원 내과학교실) ;
  • 황인혜 (부산대학교 의학전문대학원 내과학교실) ;
  • 김일영 (부산대학교 의학전문대학원 내과학교실) ;
  • 이하린 (부산대학교 의학전문대학원 내과학교실) ;
  • 성은영 (부산대학교 의학전문대학원 내과학교실) ;
  • 송상헌 (부산대학교 의학전문대학원 내과학교실) ;
  • 이동원 (부산대학교 의학전문대학원 내과학교실) ;
  • 이수봉 (부산대학교 의학전문대학원 내과학교실) ;
  • 곽임수 (부산대학교 의학전문대학원 내과학교실)
  • Published : 2012.09.01
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Abstract

Background/Aims: Cardiovascular complications are commonly seen in patients with chronic kidney disease (CKD). Recently, the prevalence of left ventricular diastolic dysfunction (LVDD) has increased, and the importance of LVDD has emerged in patients with CKD. The objectives of this study were to identify diagnostic criteria for LVDD related to ischemic heart disease (IHD) and evaluate the prognostic impact of diastolic dysfunction in patients with CKD. Methods: A total of 71 patients with CKD who were evaluated between January 2005 and May 2010 were included in this study. These patients were evaluated by conventional echocardiography and tissue Doppler imaging (TDI) for diastolic dysfunction. Results: Diagnostic cutoff values for LVDD related to IHD were E/E' = 15.55 (sensitivity: 100%, specificity: 64.7%, p = 0.005) and E/A = 0.79 (sensitivity: 84.6%, specificity: 55.9%, p = 0.006). Group I consisted of 19 patients with an E/E' > 15.55 and E/A > 0.79. Group II consisted of the remaining patients. Factors contributing to LVDD were age, history of ischemic heart disease, anemia, and high low-density lipoprotein (LDL) level. Factors contributing to IHD were LVDD, smoking, high LDL level, and high parathyroid hormone (PTH) level. The disease-free survival for IHD was significantly lower in group I compared to group II (p = 0.001). However, there was no significant difference in overall survival between groups I and II (p = 0.177). Conclusions: Our study showed that moderate LVDD (E/E' > 15.55 and E/A > 0.79) in patients with CKD is positively associated with IHD.

목적: 만성 실질환 환자에서 허혈성 심질환은 주된 사망원인으로, 이와 연관된 위험인자를 파악하고 관리하는 것은 중요하다. 허혈성 심질환과 관련된 심장의 구조적인 변화 중 특히 좌심실 이완기능 장애는 최근 발생률이 증가하고 있으며, 예후 또한 불량한 것으로 보고되고 있다. 따라서 본 연구는 만성 실질환 환자를 대상으로 심초음파를 이용하여 좌심실 이완기능 장애를 진단하고, 좌심실 이완기능 장애가 사망률 및 허혈성 심질환의 발생률에 미치는 영향에 대하여 알아보고자 하였다. 방법: 2005년 1월부터 2010년 5월까지 본원에서 심초음파를 시행한 만성 실질환 환자 중, 좌심실 구혈률이 55% 미만, 중등도 이상의 판막질환이 있는 환자와 관찰기간이 6개월 미만인 환자를 제외한 71명의 환자를 대상으로 하였다. 임상적 지표들은 의무기록 조사를 통해 수집하였고, 심초음파 검사, 혈액검사를 후향적으로 분석하였다. 결과: ROC curve를 이용한 허혈성 심질환과 연관된 좌심실 이완기능 장애의 진단 기준값은 E/E' = 15.55 (sensitivity: 100%, specificity: 64.7%, p = 0.005), E/A = 0.79 (sensitivity: 84.6%, specificity: 55.9%, p = 0.006)였다. 이 값을 기준으로 E/E` > 15.55, E/A > 0.79인 19명을 좌심실 이완기능 장애가 있는 환자군, Group I으로 지정하였고, 그 외 나머지 환자 52명을 Group II로 나누었다. 심초음파에서 Group I의 E/A, DT, E/E' 값은 각각 1.27, 184.21, 19.08이었고 Group II에서는 0.73, 225.19, 13.58이었다(E/A, p < 0.001; DT, p = 0.017; E/E', p < 0.001). 좌심실 이완기능 장애에 영향을 미치는 인자를 분석하였고 연령, 허혈성 심질환의 병력, 낮은 혈색소 수치, 높은 저밀도 지단백 수치가 관련이 되었다. 또한 허혈성 심질환을 야기시키는 위험인자를 분석하였을 때는 좌심실 이완기능 장애, 흡연, 높은 저밀도 지단백 수치, 높은 부갑상선 호르몬 수치가 상관관계가 있었다. 좌심실 이완기능 장애와 사망률 사이의 연관성을 살펴보면, 전체 사망률은 Group I, II에서 유의한 차이를 보이지 않았지만(p = 0.177), 허혈성 심질환을 나타내는 disease free survival로 비교하면 Group I이 Group II 보다 의미있게 생존율이 감소하였다(p = 0.001). 결론: 만성 신질환 환자에서 좌심실 수축기능이 정상이라도 E/E' > 15.55, E/A > 0.79인 중등도 좌심실 이완기능 장애를 가진 환자는 허혈성 심질환의 발생률이 높았다.

Keywords

References

  1. Levey AS. Controlling the epidemic of cardiovascular disease in chronic renal disease: where do we start? Am J Kidney Dis 1998;32(5 Suppl 3):S5-S13. https://doi.org/10.1053/ajkd.1998.v32.pm9820463
  2. Jin DC. Current status of dialysis therapy in Korea. Korean J Intern Med 2011;26:123-131. https://doi.org/10.3904/kjim.2011.26.2.123
  3. Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32(5 Suppl 3):S112-S119. https://doi.org/10.1053/ajkd.1998.v32.pm9820470
  4. Longenecker JC, Coresh J, Powe NR, et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002;13:1918-1927. https://doi.org/10.1097/01.ASN.0000019641.41496.1E
  5. Gulel O, Soylu K, Yuksel S, et al. Evidence of left ventricular systolic and diastolic dysfunction by color tissue Doppler imaging despite normal ejection fraction in patients on chronic hemodialysis program. Echocardiography 2008;25: 569-574. https://doi.org/10.1111/j.1540-8175.2008.00657.x
  6. Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive heart failure: echocardiographic insights. Am J Med 1983;75:750-755. https://doi.org/10.1016/0002-9343(83)90403-5
  7. Vasan RS, Benjamin EJ, Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: an epidemiologic perspective. J Am Coll Cardiol 1995;26:1565-1574. https://doi.org/10.1016/0735-1097(95)00381-9
  8. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006;355:251-259. https://doi.org/10.1056/NEJMoa052256
  9. Abhayaratna WP, Marwick TH, Smith WT, Becker NG. Characteristics of left ventricular diastolic dysfunction in the community: an echocardiographic survey. Heart 2006; 92:1259-1264. https://doi.org/10.1136/hrt.2005.080150
  10. Bhatia RS, Tu JV, Lee DS, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med 2006;355:260-269. https://doi.org/10.1056/NEJMoa051530
  11. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009;22: 107-133. https://doi.org/10.1016/j.echo.2008.11.023
  12. Paulus WJ, Tschope C, Sanderson JE, et al. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 2007;28: 2539-2550. https://doi.org/10.1093/eurheartj/ehm037
  13. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF/AHA/ WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525-2538. https://doi.org/10.1093/eurheartj/ehm355
  14. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation: Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-470. https://doi.org/10.7326/0003-4819-130-6-199903160-00002
  15. Tschope C, Kasner M, Westermann D, Gaub R, Poller WC, Schultheiss HP. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. Eur Heart J 2005; 26:2277-2284. https://doi.org/10.1093/eurheartj/ehi406
  16. Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ. Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 2003;289:194-202. https://doi.org/10.1001/jama.289.2.194
  17. Wang AY, Wang M, Lam CW, Chan IH, Zhang Y, Sanderson JE. Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease. Hypertension 2008;52:107-114. https://doi.org/10.1161/HYPERTENSIONAHA.108.112334
  18. Sharma R, Pellerin D, Gaze DC, et al. Mitral peak Doppler E-wave to peak mitral annulus velocity ratio is an accurate estimate of left ventricular filling pressure and predicts mortality in end-stage renal disease. J Am Soc Echocardiogr 2006;19:266-273. https://doi.org/10.1016/j.echo.2005.10.006
  19. Norton GR, Woodiwiss AJ, Gaasch WH, et al. Heart failure in pressure overload hypertrophy: the relative roles of ventricular remodeling and myocardial dysfunction. J Am Coll Cardiol 2002;39:664-671. https://doi.org/10.1016/S0735-1097(01)01792-2
  20. Julius BK, Spillmann M, Vassalli G, Villari B, Eberli FR, Hess OM. Angina pectoris in patients with aortic stenosis and normal coronary arteries: mechanisms and pathophysiological concepts. Circulation 1997;95:892-898. https://doi.org/10.1161/01.CIR.95.4.892
  21. Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy: clinical spectrum and treatment. Circulation 1995;92:1680-1692. https://doi.org/10.1161/01.CIR.92.7.1680
  22. Bell DS. Diabetic cardiomyopathy. A unique entity or a complication of coronary artery disease? Diabetes Care 1995;18:708-714. https://doi.org/10.2337/diacare.18.5.708
  23. Poirier P, Bogaty P, Garneau C, Marois L, Dumesnil JG. Diastolic dysfunction in normotensive men with wellcontrolled type 2 diabetes: importance of maneuvers in echocardiographic screening for preclinical diabetic cardiomyopathy. Diabetes Care 2001;24:5-10. https://doi.org/10.2337/diacare.24.1.5
  24. Fleg JL, Morrell CH, Bos AG, et al. Accelerated longitudinal decline of aerobic capacity in healthy older adults. Circulation 2005;112:674-682. https://doi.org/10.1161/CIRCULATIONAHA.105.545459
  25. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996;49:1379-1385. https://doi.org/10.1038/ki.1996.194
  26. Hayashi SY, Rohani M, Lindholm B, et al. Left ventricular function in patients with chronic kidney disease evaluated by colour tissue Doppler velocity imaging. Nephrol Dial Transplant 2006;21:125-132. https://doi.org/10.1093/ndt/gfi075
  27. Amann K, Ritz E, Wiest G, Klaus G, Mall G. A role of parathyroid hormone for the activation of cardiac fibroblasts in uremia. J Am Soc Nephrol 1994;4:1814-1819.
  28. Singh NP, Sahni V, Garg D, Nair M. Effect of pharmacological suppression of secondary hyperparathyroidism on cardiovascular hemodynamics in predialysis CKD patients: a preliminary observation. Hemodial Int 2007;11:417-423. https://doi.org/10.1111/j.1542-4758.2007.00211.x
  29. Andersson P, Rydberg E, Willenheimer R. Primary hyperparathyroidism and heart disease: a review. Eur Heart J 2004;25:1776-1787. https://doi.org/10.1016/j.ehj.2004.07.010
  30. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002;39(2 Suppl 1):S1-S266. https://doi.org/10.1016/S0272-6386(02)70081-4
  31. Oguzhan A, Arinc H, Abaci A, et al. Preload dependence of Doppler tissue imaging derived indexes of left ventricular diastolic function. Echocardiography 2005;22:320-325. https://doi.org/10.1111/j.1540-8175.2005.03177.x
  32. Galetta F, Cupisti A, Franzoni F, Carpi A, Barsotti G, Santoro G. Acute effects of hemodialysis on left ventricular function evaluated by tissue Doppler imaging. Biomed Pharmacother 2006;60:66-70. https://doi.org/10.1016/j.biopha.2005.10.008
  33. Hayashi SY, Brodin LA, Alvestrand A, et al. Improvement of cardiac function after haemodialysis: quantitative evaluation by colour tissue velocity imaging. Nephrol Dial Transplant 2004;19:1497-1506. https://doi.org/10.1093/ndt/gfh205
  34. Fatema K, Hirono O, Takeishi Y, et al. Hemodialysis improves myocardial interstitial edema and left ventricular diastolic function in patients with end-stage renal disease: noninvasive assessment by ultrasonic tissue characterization. Heart Vessels 2002;16:227-231. https://doi.org/10.1007/s003800200029
  35. Fijalkowski M, Koprowski A, Gruchala M, et al. Effect of preload reduction by hemodialysis on myocardial ultrasonic characterization, left atrial volume, and Doppler tissue imaging in patients with end-stage renal disease. J Am Soc Echocardiogr 2006;19:1359-1364. https://doi.org/10.1016/j.echo.2006.05.020
  36. Daschner M, Lenhartz H, Bötticher D, et al. Influence of dialysis on plasma lipid peroxidation products and antioxidant levels. Kidney Int 1996;50:1268-1272. https://doi.org/10.1038/ki.1996.437